ETHICAL DECISION MAKING

DIVISI BIOETIKA DAN MEDIKOLEGAL

FK USU
2009
Physicians are able to approach patients
and their families and friends in intricate
ways, bodily, emotionally, psychologically
and socially.
This is based on the publics trust in the
competency, expertise and ethics
embodied by the medical profession.
Medicine shows a long history of such
solemn pledges, embodied in oaths and
conducts of codes.
This expresses the fact that physician
have oppurtunities to intervence with the
patient: inspecting the body, asking
intimate questions, and rearranging the
lives of patients, of their families and of
society.
This privileged position of the physician
requires a high standard of
professionalism, competence and ethical
attitude and values

Ethical decision making in practise is a complex
process, such as :
A patient visits the gynecologist because of
abdominal pain . She says that she cannot
explain the pain, because her uterus has been
extirpated. The physician ask various question :
How long does she have these complaints? Is
the pain always on the same place? The patient
responds and report that she has moreover
constipation. Then, the gynecologist ask if she is
worrying. The patient says that she is afrais of
cancer. The gynecologist proposes an internal
examination.
But the patient reacts negatively. She doubts
whether an internal examination provides
enough information and prefer a laparascopy.
The physician states that each methods has its
advantages and disadvantages and that he has
to examine her first in order to be able to decide
on further steps. After the examination he
proposes to consult a dietician, to help to relieve
the constipation. He repeat his objections
againts such a dramatic investigation as a
laparoscopy. Moreover, he emphasizes that
such an examination does not provide full
certainty. When henproposes that a laparoscopy
can always be performed later on, the patient
agrees with his proposal.
How would we assess such a case? It
depends on the ethical perspective one
takes. Feeling of easiness or uneasiness
in decision making in medical practise
depend not only on whether the presented
case notifies a rational, efficient and
technically adequate course of action, but
also on whats should have happened.
That is, w/hether it is good what has
happened
Some Ethical Perspectives
1. The Hipocratic-biomedical approach
The physician is attentive and careful for the
good of the patient. The guiding principles are
beneficence, doing good, and nonmalificence,
doing no harm. The physician has to decide
what responsible medical acting is and
objectify what the best interest of the patient is
: doctor knows best . This paternalistic
tradition is still very influential in medicine and
despite many objection helpful in various
circumstances, such as emergency situations
or with incompetent patient
2. The principle ethics approach
Next to the principles of beneficence and
nonmaleficence, the principles of
autonomy and justice become dominant.
If the best interest of the patient is at
stake, who else than the patient him or
her self can and should desice what is
the best interest? Decisions of
physicians need to be based on the
informed consent of the patient.
3. The interpretative ethics approach
Interpretative approaches do start from
Aristotelian tradition that in practise human
being, patients and professionals are already
oriented on the good and the good life. The
moral experiences and motivations of the
concerned persons are the starting point: what
do they find evident and what do they find
difficult? What do they strife for? What do they
want to avoid. The case is about more than
only autonomy or doing good (or do no harm),
it is a conversation about fear, uncertainty and
prospects.
4. Collaborative or dialogical ethics approach
This approach integrates elements of the
previous approach, stressing that medical
practise is an encounter between persons,
each with a set of values, preferences and
perspestives, which have to evolve and to
interact. Collaborative decision making places
emphasis on the fact that physician and patient
should work together in medical decision
making and ultimately strive for same goal:
putting to use medical knowledge and
techniques to improve the well-being of the
patient in comformity with his or her own
values and life plan.
Conclusions
Ethical decision making is not a single
event, but a process.
Medical facts and technique express as
much values and preferences of
physicians as patients enter the process
with their values and preferences.
Values and preferences are not only in the
heads of physician s, they are embedded
in the routines, organization, protocols and
guidelines of everyday hospital practice.

Patient's values, goals and preferences
should guide the decision making process,
but this requires more than 'better talking,
it also requires changes in attitude,
perspectives as well as institutional and
organizational arregements.
Ethical decision making is not ethicists
telling physicians how to do the trick, but a
practice in which physicians and patients,
in collaboration with other health care
workers, put in their expertise, their skills
and their values and moral experiences.